Texas Tech University Health Sciences Center
Enrollment in managed care plans

Enrollment in managed care plans

enrollment-in-managed-care-plans- image0Texas Tech Physicians often has issues with our new faculty physicians being enrolled in a timely fashion in the managed care plans in which we participate, including governmental payers. I feel the frustration myself at times — I want us to be able to bill for services ASAP (we all do — including the individual physician).  When there are delays, it is usually not any one individual’s fault (our folks do a good job); there are just dozens of steps and it involves a lot of people including numerous sources outside the organization. Many things can go wrong along the way. I started thinking about this and looking around the Web a bit for resources and decided to write this article.

But, let’s go further upstream and consider the education of physicians and continue through to the credentialing of physicians.  It can appear daunting … because it is.  Consider, for example, the steps a person who wishes to become a physician has to undergo (and say, later, this individual wishes to become a provider for Texas Tech Physicians):

1.Graduate from high school with a high GPA

2.Earn a bachelor's degree from a four-year university and be well prepared for the Medical College Admissions Test (MCAT).

3.Take and pass the MCAT. Basically, the higher the MCAT scores, the better.

4.Graduate from medical school.

5.Complete a medical residency training program.
Residency programs are a minimum of three years, but the length varies according to medical specialty.

6.Pass the USMLE. The USMLE is a three-part exam required to obtain a medical license in the U.S.

7.Complete fellowship training. Not all medical doctors must do fellowship training. Certain specialties like cardiology and gastroenterology require fellowship training.  A fellowship program may be as short as six months or up to three years.

8.Get a state medical license. The State of Texas is well known for its demands and it can take up to 12 months to obtain a license.

9.Pass the medical board exam for specialty. The American Board of Medical Specialties certifies physicians in their respective specialties. Board certification used to be an option, but most employers (hospitals, particularly) are now requiring board certification. The board certification process consists of a written and oral exam. Board certification exams are usually only given once or twice per year, so most physicians take the test in the late summer or fall after completing residency or fellowship training in June or July.

10.Obtain local credentialing and hospital privileges. This step is required to allow a medical doctor to admit patients to a hospital, or treat patients in a hospital, including rounds and surgery, depending on the medical specialty. Obtaining privileges at a hospital usually entails filling out an application packet, and sometimes a personal interview with the hospital board members or hospital administration is also required.

11.Obtain provider numbers, DPS, and DEA numbers. Provider numbers are required from insurance companies like Medicare, or Blue Cross/Blue Shield to be reimbursed for medical services rendered. A DEA number is required to prescribe drugs like narcotics.

So, we respect our physicians for having the tenacity and talent to go through the above and for our educators, spouses, parents, credentialing experts and others that make all of this possible. As you can see, it is anything but simple.